Intake Investigator I

3 weeks ago

Los Alamitos, United States @Orchard Full time
Job DescriptionJob DescriptionIntake Investigator
Los Alamitos, CA (hybrid Tues/Thurs onsite)
@Orchard LLC is retained by a not-for-profit corporation that partners with public and private sectors to create high quality, safe, and efficient delivery of health care and human services programs. We have multiple lines of business including population health, utilization review, managed care organization quality review, and quality assurance for programs serving individuals with developmental disabilities. Our Client is also a national leader in fighting fraud, waste and abuse for large organizations across the country. In addition, our Foundation provides grant opportunities to those with programs for under-served communities.

The Intake Investigator position is the perfect opportunity for you to begin your career in healthcare fraud, waste and abuse investigation This team identifies and investigates fraud, waste and abuse in the Medicare and Medicaid programs covering 16 states and territories in the west region. We're seeking high performing candidates with a track record of exceeding expectations. Candidates possessing strong analytical, communication and MS Office skills are a great fit for this position. Attention to detail and an organized approach to your work are also key traits for success in this position. Our Client’s employees enjoy a collaborative work environment and we offer an excellent benefits package that includes healthcare, two retirement plans and a generous leave program.

The hiring range of this position is $23-25/hour in Los Alamitos, CA, based on experience.

Essential Duties and Responsibilities:
  • Enters investigative information into the case tracking systems and will meet with Lead Investigators to assign investigations to the Investigative team.
  • Works with the team to prioritize complaints for investigations.
  • Places potential fraudulent providers on prepay review and monitor adjudication of claims.
  • Analyzes data for appropriateness of fraud, waste and abuse issues in accordance with pre-established criteria, requesting additional documentation if necessary.
  • Refers all potential adverse decisions to the Lead Investigator/Manager.
  • Identifies, collects, preserves, analyzes and summarizes evidence, examining records, verifying authenticity of documents, preparing affidavits or supervising the preparation of affidavits as needed.
  • Drafts and evaluates investigation reports and promote effective and efficient investigations.
  • Initiates and maintains communications with law enforcement and appropriate regulatory agencies including presenting case findings for their consideration to further investigate, prosecute, or seek other appropriate regulatory or administrative remedies.
  • Testifies at various legal proceedings as necessary.
  • Communicates with beneficiaries and providers as needed to resolve beneficiary complaints and assists providers with medical review status.
  • Identifies opportunities to improve processes and procedures.
  • Has the responsibility and authority to perform their job and provide customer satisfaction.

Education and /or Skills and Experience Required:
  • Required:
    • An Associate’s Degree or two years’ experience in a related field that demonstrates expertise in reviewing, analyzing, and making appropriate decisions or equivalent combination of education and experience.
  • Preferred:
    • Experience in healthcare programs or fraud investigation/detection
    • Certified Fraud Examiner or Accredited Healthcare Anti-Fraud Investigator
  • Intermediate level ability to utilize Microsoft Office to include Word, Excel and Outlook.
  • Ability to work independently with minimal supervision.
  • Ability to communicate effectively with all members of the team to which he/she is assigned.
  • Ability to grasp and adapt to changes in procedure and process.
  • Ability to effectively resolve complex issues.

Established in 2010, @Orchard has an exceptional reputation, providing staffing solutions to time-sensitive, talent scarcity issues to deliver better talent management ROI. Our specialty lies in the critical area of program talent acquisition and resource management, not in one narrow skillset, but across many areas of technical and functional delivery. To learn more about our other exciting opportunities, visit our Jobs Page at www.atorchard.com.

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